A Controlled Trial of Universal Gloving vs. Contact Precautions for Preventing the Transmission of Multidrug-Resistant Pathogens

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A Controlled Trial of Universal Gloving vs.
Contact Precautions for Preventing the
Transmission of Multidrug-Resistant Pathogens
G. Bearman, MD, MPH A. Marra, MD C. Sessler,
MD W.R. Smith, MD R.P. Wenzel MD, MSc M.B.
Edmond, MD, MPH, MPA
Disclosure nothing to disclose
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Hypothesis

• The effectiveness of universal gloving (use of
  gloves for all patient care activity) in
  preventing the transmission of multidrug-resistant
  pathogens will be greater than the effectiveness
  of contact precautions since compliance with
  universal gloving will be greater than compliance
  with contact precautions (gown and glove use).

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MethodsSetting

• 12-bed medical ICU in an 820-bed, tertiary care,
  academic medical center
• Closed-ICU staffing model with 5 attending
  intensivists

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Methods Study Design
Phase I
Phase II
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MethodsSurveillance

• CDC/NNIS NI definitions used surveillance
  performed by experienced ICPs
• Hand hygiene observations performed by trained
  observers
• Active microbiologic surveillance nasal and
  rectal cultures obtained on all patients in the
  unit

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Methods Microbiologic Studies

• One rectal swab culture for VRE and one nasal
  swab culture for MRSA performed on admission and
  every 4 days
• Once a patient was culture positive, no further
  cultures were obtained for that organism
• Pulse field gel electrophoresis (PFGE) for
  genetic typing and antibiotic susceptibility
  testing were performed on all MRSA and VRE
  isolates

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MethodsHealthcare Worker Questionnaire

• 15 item survey was administered at the end of the
  study protocol
• Target MICU nurses and attending physicians
• Focus
• self reported compliance with infection control
  practice
• acceptability of universal gloving vs. standard
  of care

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MethodsAdditional Data Elements
Phase I vs. Phase II
Length of stay
MICU occupancy rate per month
MICU invasive devices utilization ratios
Nurse to patient ratio
Antibiotic usage defined daily dose (DDD)
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Results
Variable Phase I Phase II P value
Total patient days 1,090 1,377 -
Total observations for IC compliance 1,220 1,102 -
Total patients screened for VRE 192 257 0.54
Total patients screened for MRSA 228 301 0.60
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Results Hand Hygiene Compliance
Phase I Contact Precautions Phase I Contact Precautions Phase II Universal Gloving Phase II Universal Gloving
Hand hygiene N Obs N Obs P-value
Before patient contact 228 18.7 126 11.4 lt0.001
After patient contact 704 57.7 578 52.5 0.011
A statistically significant reduction in
hand-hygiene was observed in phase II
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Results Compliance with Contact Precautions vs.
Universal Gloving
Variable Phase I Phase I Phase II Phase II P
Variable N N P
Compliance with gloving for patients on contact precautions 387 89.4 N/A N/A N/A
Compliance with gowns for patients on contact precautions 335 77.4 N/A N/A N/A
Compliance with gowns and gloves for patients on contact precautions 328 75.7 N/A N/A N/A
Total compliance contact precautions vs. universal gloving 328 75.7 959 87.0 lt0.001
Greater adherence during universal gloving was
observed
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Results VRE screening
Variable Phase I Contact Precautions Phase II Universal Gloving P value
Patients screened for VRE 192 257
Patients VRE positive upon admission to ICU 3 (1.5) 3 (1.1) 0.70
Patients with VRE conversion during ICU stay 39 (20) 35 (14) 0.31
Days to acquire VRE (median) 8 9 0.79
No difference was observed in the rate of VRE
acquisition
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Results MRSA Screening
Variable Phase I Phase II P value
Patients screened for MRSA 228 301 -
Patients MRSA positive upon admission to ICU 11 (4.8) 6 (2.0 ) 0.11
MRSA conversion during ICU stay 13 (5.7) 15 (5.0) 0.92
Days to acquire MRSA (median) 8 9 0.95
No difference was observed in the rate of MRSA
acquisition
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Results MRSA PFGE
MRSA Phase I Phase II
Number of strains 21 25
Conversion negative to positive 13 13/13 clonal or related (100) Type A1, A2, A3, A4 15 15/15 clonal or related(100) Type A1, A5
PFGE types A1 13 (62) A2 5 (23) A3 1 (5) A4 1 (5) B 1 (5) A1 18 (72) A5 2 (8) C 3 (12) D 2 (8)
All MRSA conversions were with clonal or related
isolates
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Results VRE PFGE
VRE Phase I Phase II
Number of Strains 40 35
Conversion negative to positive 39 20/40 clonal (50) Type A, B 35 28/35 clonal (80) Type A, AA, AB
PFGE Types Type A 16 (34) Type B 4 (11) Type D 2 Type G 3 Type H 2 Type J 2 Type K 2 Types C,E,I, L,M,Q,R S,T 1 each Type A 18 (51) Type AA 4 (11) Type AB 4 (11) Type H 2 (6) Types F,G,I,J,U,V,M 1 each
Most VRE conversions were with clonal or related
isolates
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ResultsNosocomial Infections Rates
Outcome Phase I Phase II P
BSI/ 1,000 catheter days 6.2 14.1 Plt0.001
UTI/ 1,000 catheter days 4.3 7.4 Plt0.001
Pneumonia/ 1,000 ventilator days 0 2.3 Plt0.001
A statistically significant increase in NIs was
observed
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Results Nosocomial Infections
Phase I Phase I Phase II Phase II
Infection Organisms Organisms
BSI 5 P. aeruginosa (1) E. cloacae (1) K. pneumoniae (1) Prevotella spp (1) C. glabrata (1) 16 Coag. negative staph (6) Enterococcal spp (3) VRE (1) MRSA(2) P. aeruginosa (1) K. pneumoniae (1) C. parapsilosis (1) C. albicans (1)
UTI 6 E. coli (2) E. cloacae (1) C. albicans (3) 9 Coag. negative staph (1) Enterococcal spp (1) P. aeruginosa (2) E. coli (1) C. albicans (2) C. non-albicans (2)
VAP 0 NA 2 MRSA(1) P. aeruginosa (1)
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Results Nosocomial Infections with VRE or MRSA
Phase I Phase I Phase II Phase II
Infection VRE MRSA VRE MRSA
BSI 0 0 1 2
UTI 0 0 0 0
VAP 0 0 0 1
4 infections with either VRE or MRSA were
identified in Phase II
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Results MICU Additional Data
Phase I Phase II P value Variable
5.3 6.8 0.07 Average length of stay (days)
87 92 0.36 MRICU occupancy rate/month
11.9 11.9 NS Nurse to patient ratio
Device utilization ratio Phase I Phase II P
Urinary Catheter 0.85 0.87 0.83
Central line 0.74 0.72 0.87
Ventilator 0.56 0.62 0.47
Utilization ratiodevice days/patient days
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Results Antibiotic UsageDefined daily dose
(DDD/1000 patients-days)
Antibiotic DDD Phase I DDD Phase II P value
?-lactams 391.6 352.9 0.075
?-lactam/inhibitor 210.1 211.5 1.0
Aminoglycosides 68.2 118.2 lt0.001
Glycopeptides 190.1 226 0.079
Metronidazole 127.0 118.6 0.582
Quinolones 385.7 359.0 0.206
Total 1372.7 1386.2 0.806
The DDD is the assumed average maintenance dose
per day for a drug used for its main indication
in adults Example DDD of levofloxacin is 0.5
grams, if 200 grams were dispensed in a period
with 4,500 patient days (200g/0.5g)/4,500 pt
days X 1000 89 DDD/1000 PD
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Conclusions

• Observed compliance with universal gloving was
  significantly greater than compliance with
  contact precautions (gowns and gloves).
• However, greater compliance with hand hygiene was
  observed in the contact precautions phase.
• No differences were detected between the two
  study phases for
• LOS, nurse/patient ratio, MICU occupancy rate,
  invasive device utilization, antibiotic usage

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Conclusions

• No differences in VRE and MRSA colonization were
  observed between the two study phases
• In both phases, the majority of VRE and MRSA
  conversions were of a clonal or related isolate
• However, an increase in nosocomial infection
  rates was observed during the universal gloving
  phase of the study
• 4 VRE/MRSA nosocomial infections were observed
  during the universal gloving phase

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Conclusions

• Although universal gloving was highly accepted by
  the staff, its implementation should proceed with
  caution given the observed increase in nosocomial
  infection rates
• The use of universal gloving may have led to a
  misperception of decreased cross transmission
  risk
• This may have lead to decreased hand hygiene
  compliance and a consequent increase in the rates
  of nosocomial infections

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Conclusions

• Due to short study period (6 months)
• The observed increase in nosocomial infections
  may have been a result of normal variation and
  may not have been attributed to the universal
  gloving intervention.

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Criteria for PFGE interpretation
Category of Fragment Differences Inferred relationship
Indistinguishable 0 Isolate represents the outbreak strain
Closely related 2-3 Isolate probably represents the outbreak strain
Possibly related 4-6 Isolate possibly represents the outbreak strain
Different gt7 Isolate is different from outbreak strain
Tenover et al.J.Clin Microbiol. 1995.
322233-2239.